Minimally invasive endoscopic evacuation with the novel, portable Axonpen neuroendoscopic system for spontaneous intracerebral hemorrhage.

Minimally invasive surgeries have shown potential to improve mortality and clinical outcomes of spontaneous intracerebral hemorrhage (ICH). The present study assessed the first-in-human outcomes of a novel, portable neuroendoscopic system for ICH evacuation at our single center. This neuroendoscopic system integrates real-time visualization into a handpiece which has controllable suction, irrigation, and coagulation to allow a neurosurgeon to conduct minimally invasive ICH evacuation independently with bimanual dexterity. Pre- and postoperative data of ten patients who had spontaneous basal ganglia hemorrhage (mean: 46.5 ± 12.2 mL) and underwent evacuation with the specified neuroendoscopic system were collected prospectively. The mean time to receive surgery was 12.1 ± 7.6 h. Mean operative time was 3.4 ± 0.9 h. The mean hematoma volume decreased to 6.0 ± 3.9 mL at postoperative 6 h, resulting in a mean volume reduction of 86.0 ± 11.2% (P = 0.005). The median length of intensive care unit stay was 3 days (IQR, 3-4 days). At discharge, the median Glasgow Coma Scale (GCS) score significantly improved to 11.5 (IQR, 11-15; P = 0.016), and the median modified Rankin Scale (mRS) score was 4 (IQR, 4-5). Six patients (60%) showed a favorable mRS score of ≤ 3 on their last return visit. Neither death nor rebleeding occurred during the follow-up periods. Integrated design of the innovative device is valuable to optimize minimally invasive endoscopic ICH evacuation procedure. Further studies are needed to clarify long-term benefits from such type of the innovative device to early intervention of ICH.

Removal of electrical stimulus artifact in local field potential recorded from subthalamic nucleus by using manifold denoising.

BACKGROUND: Deep brain stimulation (DBS) is an effective treatment for movement disorders such as Parkinson's disease (PD). However, local field potentials (LFPs) recorded through lead externalization during high-frequency stimulation (HFS) are contaminated by stimulus artifacts, which require to be removed before further analysis. NEW METHOD: In this study, a novel stimulus artifact removal algorithm based on manifold denoising, termed Shrinkage and Manifold-based Artifact Removal using Template Adaptation (SMARTA), was proposed to remove artifacts by deriving a template for each stimulus artifact and subtracting it from the signal. Under a low-dimensional manifold assumption, a matrix denoising technique called optimal shrinkage was applied to design a similarity metric such that the template for stimulus artifacts could be accurately recovered. RESULT: SMARTA was evaluated using semirealistic signals, which were the combination of semirealistic stimulus artifacts recorded in an agar brain model and LFPs of PD patients with no stimulation, and realistic LFP signals recorded in patients with PD during HFS. The results indicated that SMARTA removes stimulus artifacts with a modest distortion in LFP estimates. COMPARISON WITH EXISTING METHODS: SMARTA was compared with moving-average subtraction, sample-and-interpolate technique, and Hampel filtering. CONCLUSION: The proposed SMARTA algorithm helps the exploration of the neurophysiological mechanisms of DBS effects.

Long-term outcomes of coils embolization for superior hypophyseal artery aneurysms.

Objective: Superior hypophyseal artery (SHA) aneurysms are intradural, and their rupture can result in subarachnoid hemorrhage. Considering the related surgical difficulty and anatomical restrictions, endovascular treatment (EVT) is considered the most favorable modality for SHA aneurysms; however, the long-term outcomes of EVT have rarely been reported. The study assessed the incidence of and risk factors for recurrence of SHA aneurysms after EVT as well as the correlation factors for SHA aneurysm rupture. Methods: We included 112 patients with SHA aneurysms treated with EVT at our facility between 2009 and 2020. Here, EVT included non-stent-assisted (simple or balloon-assisted) or stent-assisted coiling. Flow diverter was not included because it was barely used due to its high cost under our national insurance's limitation, and a high proportion of ruptured aneurysms in our series. Univariate and multivariate logistic regression was performed to evaluate the correlation factors for SHA aneurysm rupture, along with the incidence of and risk factors for post-EVT SHA aneurysm recurrence and re-treatment. Results: In our patients, the mean angiographic follow-up period was 3.12 years. The presence of type IA or IB cavernous internal carotid artery (cICA) was strongly correlated with SHA aneurysm rupture. Recurrence occurred in 17 (13.4%) patients, of which only 1 (1.4%) patient had received stent-assisted coiling. All cases of recurrence were observed within 2 years after EVT. The multivariate logistic regression results showed that ruptured aneurysm and non-stent-assisted coiling were independent risk factors for aneurysm recurrence. Of the 17 cases of aneurysm recurrence, 9 (52.9%) received re-treatment. Moreover, aneurysm rupture was the only factor significantly correlated with re-treatment in multivariate logistic regression. No re-recurrence was observed when a recurrent aneurysm was treated with stent-assisted coiling. Conclusion: Type I cICA was common factor for aneurysm rupture. Although flow-diverter treatment serves as another suitable technique that was not compared with, coils embolization was effective treatment modality for SHA aneurysms, leading to low recurrence and complication rates, especially with stent use. All cases of recurrence occurred within 2 years after EVT; they were strongly associated with prior aneurysm rupture. Further stent-assisted coiling was noticed to prevent re-recurrence.

Using a continuous electrocardiographic patch with heart rhythm analysis in the subacute stage of aneurysmal subarachnoid hemorrhage: The feasibility verification.

OBJECTIVE: Continuous cardiac monitoring on patients with aneurysmal subarachnoid hemorrhage (aSAH) is difficult out of intensive care unit (ICU) in the subacute stage. Therefore, we verified the feasibility of a novel electrocardiography (ECG) patch device to record long-term heart rhythm. METHODS: The ECG patches were applied on aSAH patients during their stay in general ward. Any types of significant arrythmia were identified, and heart rate variability (HRV) measures were calculated in time and frequency domains. We analyzed the correlation between heart rhythm with Hunt and Hess scale and modified Fisher scale as well as the occurrence of secondary complications. RESULTS: Twenty-six patients used the devices on median day 6 after aSAH onset, with put on and take down time average as 137 s and 45 s, respectively. Mean record time was 221.7 h, and no adverse event presented within the period. Hunt and Hess II/III subgroup had higher percentage of HRV high frequency band than IV/V subgroup (9.1 % vs 3.5 %, p = 0.043), whereas ultra low frequency band presented more in the later subgroup (50.4 % vs 61.4 %, p = 0.035). The very low frequency percentage significantly decreased (p = 0.025) at an average of 3 days prior to the occurrence of secondary complications compared to the days without complications. CONCLUSION: For aSAH patients in general ward during subacute stage, the ECG patch is a safe and feasible tool. The correlation of long-term heart rhythm with prognosis is worthy to be investigated on larger sample size using this device in the future.

Subthalamic high-beta oscillation informs the outcome of deep brain stimulation in patients with Parkinson's disease.

Background: The therapeutic effect of deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's disease (PD) is related to the modulation of pathological neural activities, particularly the synchronization in the ß band (13-35 Hz). However, whether the local ß activity in the STN region can directly predict the stimulation outcome remains unclear. Objective: We tested the hypothesis that low-ß (13-20 Hz) and/or high-ß (20-35 Hz) band activities recorded from the STN region can predict DBS efficacy. Methods: Local field potentials (LFPs) were recorded in 26 patients undergoing deep brain stimulation surgery in the subthalamic nucleus area. Recordings were made after the implantation of the DBS electrode prior to its connection to a stimulator. The maximum normalized powers in the theta (4-7 Hz), alpha (7-13 Hz), low-ß (13-20 Hz), high-ß (20-35 Hz), and low-γ (40-55 Hz) subbands in the postoperatively recorded LFP were correlated with the stimulation-induced improvement in contralateral tremor or bradykinesia-rigidity. The distance between the contact selected for stimulation and the contact with the maximum subband power was correlated with the stimulation efficacy. Following the identification of the potential predictors by the significant correlations, a multiple regression analysis was performed to evaluate their effect on the outcome. Results: The maximum high-ß power was positively correlated with bradykinesia-rigidity improvement (r s = 0.549, p < 0.0001). The distance to the contact with maximum high-ß power was negatively correlated with bradykinesia-rigidity improvement (r s = -0.452, p < 0.001). No significant correlation was observed with low-ß power. The maximum high-ß power and the distance to the contact with maximum high-ß power were both significant predictors for bradykinesia-rigidity improvement in the multiple regression analysis, explaining 37.4% of the variance altogether. Tremor improvement was not significantly correlated with any frequency. Conclusion: High-ß oscillations, but not low-ß oscillations, recorded from the STN region with the DBS lead can inform stimulation-induced improvement in contralateral bradykinesia-rigidity in patients with PD. High-ß oscillations can help refine electrode targeting and inform contact selection for DBS therapy.

The Prognostic Impacts of Body Mass Index and Distance to the Peritoneal Bottom on Laparoscopic Ventriculoperitoneal Shunt Placement.

OBJECTIVE: Laparoscopic ventriculoperitoneal shunt surgery has been reported to have several advantages in selected patients. However, the prognostic factors have been understudied specifically for this surgery. We sought to investigate the factors influencing the complications after the laparoscopic ventriculoperitoneal shunt placement. METHODS: All surgeries in this prospective study were performed by the same team of neurosurgeons and general surgeons. Clinical parameters as well as potential risk factors for postoperative complications were analyzed. The endpoint was overall complications requiring surgical revision within the follow-up period after surgery. RESULTS: Ninety-nine patients (51 male and 48 female) scheduled for laparoscopic-assisted ventriculoperitoneal shunt surgery between 2019 and 2021 were included. Overall shunt complication rate was 9% (9 of 99 cases), and there was 1 patient (1%) who had distal dysfunction among them. Body mass index ≥27 kg/m2 (hazard ratio 4.87; 95% confidence interval 1.05-22.57; P = 0.043), and nonprogrammable shunts (hazard ratio 7.91; 95% confidence interval 1.51-41.50; P = 0.014) were significantly associated with an increased risk of complications. Among 75 patients who received programmable shunts, the vertical distance from the distal tip to the presumed bottom of peritoneal cavity was significant positively associated with the number of pressure adjustments (R2 0.511, adjusted R2 0.504, and P < 0.001). CONCLUSIONS: Ventriculoperitoneal shunt surgery provided benefits with little complication rate, whereas patients treated with nonprogrammable shunts and obese patients had less favorable outcome. A positive correlation between the vertical distance from the distal tip to the bottom of peritoneal cavity and pressure adjustments inferred to the advantage of the laparoscopic method.

Spinal cord injury and spinal fracture in patients with ankylosing spondylitis.

BACKGROUND: Spinal cord injury (SCI) and spinal fracture are major complications in patients with ankylosing spondylitis (AS) who sustain spinal trauma. The purpose of this study was to investigate the incidence, predictors, and sequelae of spinal trauma in patients with AS. METHODS: This retrospective study included patients with AS who were admitted for spinal trauma between January 1, 2006, and June 30, 2016. The study compared clinical outcomes of patients between group 1: SCI alone, group 2: spinal fracture alone (no SCI), and group 3: both SCI and spinal fracture. RESULTS: Of the 6285 patients with AS admitted during the retrospective study period, only 105 suffered from spinal trauma and were enrolled in the study. Case number in group 1, 2, and 3 was 11(10.48%), 45(42.85%), and 49(46.67%), respectively. Among the patients with spinal fractures, 52.1% had SCI. Bamboo spine was significantly more prevalent in the fracture group than in the nonfracture group (78.7% vs. 36.4%; P = 0.006). Patients with SCI had more instances of subluxation or dislocation (48.3% vs. 8.9%; P < 0.001) and more cases of spinal epidural hematoma (SEH; 21.7% vs. 2.2%; P = 0.003) than patients without SCI. The rate of delayed diagnosis for spinal fracture was 31.4%, with one-third of patients developing delayed SCI. Among the patients with incomplete SCI, 58.3% achieved neurological improvement after treatment (P = 0.004). CONCLUSIONS: Patients with AS and bamboo spine at radiograph had a higher rate of spinal fracture, which may be an important factor in SCI in patients with AS. Spinal fractures involving the C3-C7 region, subluxation or dislocation, severe spinal fracture, and SEH were found to be predictive of SCI, and SCI in patients with AS resulted in higher mortality and complication rates.

Delayed Progressive Mass Effect After Secured Ruptured Middle Cerebral Artery Aneurysm: Risk Factors and Outcomes.

Objective: Delayed progressive mass effect (DPME) after securing an aneurysm is uncommon following microsurgical or endovascular repair and leads to a poor clinical outcome. Patients with ruptured middle cerebral artery (MCA) aneurysms have a high risk of postoperative oedema and mass effect, which may require decompressive treatment. Because few studies have discussed the risk and predictive factors, we focused on ruptured MCA aneurysms and evaluated the outcomes of these patients and the necessity of salvage surgery when DPME presented. Methods: Data on 891 patients with aneurysmal subarachnoid haemorrhage (aSAH) treated between January 2011 and February 2020 were extracted from the medical database of a tertiary referral centre. A total of 113 patients with aSAH resulting from at least one MCA aneurysm were identified. After excluding patients with several clinical confounders, we enrolled 80 patients with surgically treated aSAH. We examined the characteristics of aneurysms and hematomas, perioperative contrast pooling patterns, presence of distal hematomas, perisylvian low density, occlusive treatment modality, management strategies, the need for salvage surgical decompression, and postoperative 90-day outcomes to identify possible risk factors. Results: DPME was observed in 27 of the 80 patients (33.7%). The DPME and non-DPME group differed significantly in some respects. The DPME group had a higher risk of salvage surgery (p < 0.001) and poorer outcomes (mRS at day 90; p = 0.0018). The univariate analysis indicated that the presence of hematoma, CTA spot signs, perisylvian low density, and distal hematoma were independent risk factors for DPME. We also noted that DPME remained an independent predictor of a poorer 90-day functional outcome (mRS ≤ 2). Conclusion: DPME can lead to salvage decompression surgery and directly relates to poor outcomes for patients with a ruptured MCA aneurysm. Distal hematoma, perisylvian low density, and CTA spot signs on preoperative images can predict DPME.

The Role of Intraventricular Hemorrhage in Traumatic Brain Injury: A Novel Scoring System.

Traumatic intraventricular hemorrhage (tIVH) is associated with increased mortality and disability in traumatic brain injury (TBI). However, the significance of tIVH itself remains unclear. Our goal is to assess whether tIVH affects in-hospital mortality and short-term functional outcomes. We retrospectively reviewed the records of 5048 patients with TBI during a 5-year period, and 149 tIVH patients were analyzed. Confounding was reduced using the inverse probability of treatment weighting (IPTW) based on propensity score. The association between IVH and outcomes was investigated using logistic regression in the IPTW-adjusted cohort. In our study, after adjustment for analysis, the in-hospital mortality rate (11.4% vs. 9.2%) and the poor functional outcome rate (37.9% vs.10.6%) were significantly higher in the tIVH group than in the non-tIVH group. Factors independently associated with outcomes were age ≥ 65 years, Glasgow Coma Scale (GCS) severity score, and the Graeb score. The Traumatic Graeb Score, a novel scoring system for predicting functional outcomes associated with tIVH, comprised the sum of the following components: GCS scores of 3 to 4 (=2 points), 5 to 12 (=1 point), 13 to 15 (=0 points); age ≥ 65 years, yes (=1 point), no (=0 points); Graeb score (0-12 points). A Traumatic Graeb Score ≥ 4 is an optimal cutoff value for poor short-term functional outcomes.

The surgical strategy for multilevel massive ossification of the posterior longitudinal ligaments.

Purpose: Creating enough decompression, favorable outcome, less complication, and maintain adequate lordosis and stability in the patients with cervical myelopathy due to multilevel massive ossification of the posterior longitudinal ligament (OPLL) still poses a challenge for surgeons. The aim of our study is to retrospectively evaluate our patients and try to seek a better surgical strategy. Methods: Between 2015 and 2019, 55 consecutive patients with multilevel massive OPLL underwent surgical treatment. Among these, 40 patients were treated with cervical laminectomy and then anterior decompression, fusion, and fixation (ADF), which was defined as group 1, and 15 patients were treated with cervical laminectomy and fixation simultaneously, which was defined as group 2. The patient's radiographic characteristics and postoperative outcomes were evaluated. Results: Better postoperative cervical sagittal lordosis and less long-term axial pain was achieved in group 1 (p < 0.001), though the functional outcome had no significant difference. In the multivariable analysis, anterior fixation accounts for independent factors for better cervical sagittal alignment (p < 0.001). No complications directly associated with cervical laminectomy were observed. Conclusion: In patients with cervical multilevel massive OPLL, laminectomy at compression level and then ADF depended on the severity and range of compression, but corpectomy of not more than two vertebral bodies is suggested, except K-line (+) and long-segment massive OPLL majorly involving the C2 and posterior laminectomy above and below the OPLL-affected levels with posterior fixation simultaneously.

Rescue embolization with direct coil delivery from dual-lumen balloon microcatheter.

BACKGROUND: Balloon microcatheters are widely used for endovascular treatment. However, no reports on direct coil embolization from dual-lumen balloon microcatheters are available in the literature. This report is the first description of direct coil embolization using this type of balloon microcatheter for looming bleeding emergencies. METHODS: This retrospective review demonstrates the indications and advantages of coil embolization from an inflated balloon catheter to reduce blood loss and simultaneously occlude bleeding. RESULTS: Five patients who underwent emergency endovascular treatment using coil embolization directly delivered from a dual-lumen balloon were identified. Etiologies included vertebro-vertebral arteriovenous fistula, ruptured vertebral artery dissecting aneurysm, vertebral artery injury during cervical spinal operation, and failed stent retrieval procedures for acute infarction. Complete hemostasis was achieved with all procedures. CONCLUSION: Our experience demonstrates the feasibility of direct coil embolization by using a dual-lumen balloon to rapidly halt bleeding in some rare emergency situations, which may save lives.

Ticagrelor versus clopidogrel in stent-assisted coil embolization of unruptured intracranial aneurysms.

BACKGROUND: Dual antiplatelet therapy is widely used for stent-assisted coil embolization (SACE) for unruptured intracranial aneurysms (UIAs) to prevent thromboembolic events (TEs). Compared to clopidogrel associated with aspirin, knowledge of the safety and efficacy of ticagrelor is lacking in large studies to date. METHODS: A retrospective cohort study was conducted from January 2016 to December 2018 with at least one year of follow-up in a single institution and systemic review. RESULTS: Altogether, 153 patients with UIA receiving SACE were separated into two groups: 113 patients receiving clopidogrel plus aspirin and 40 patients receiving ticagrelor plus aspirin. Acute in-stent thrombotic events were noted in two patients in the clopidogrel group (1.77%) and none in the ticagrelor group (0%). Additionally, one patient (0.88%) in the clopidogrel group had an early ischemic stroke (<3 months). Delayed ischemic stroke was noted in 6 patients (5.31%) in the clopidogrel group and 3 patients (7.50%) in the ticagrelor group. There were no major hemorrhagic events in either group. The two groups showed no significant differences with regard to ischemic stroke or hemorrhagic stroke. CONCLUSION: Compared to the clopidogrel based regimen, ticagrelor can also reduce TEs without increasing bleeding tendency for SACE of UIAs. Ticagrelor combined with low-dose aspirin is a safe and effective alternative option for SACE.

Predictive Value of Swab Cultures for Cryopreserved Flaps During Delayed Cranioplasties.

OBJECTIVE: To assess the predictive value of swab cultures of cryopreserved skull flaps during cranioplasties for surgical site infections (SSIs). METHODS: A retrospective review was conducted of consecutive patients who underwent delayed cranioplasties with cryopreserved autografts between 2009 and 2017. The results of cultures obtained from swabs and infected surgical sites were assessed. The accuracy, sensitivity, and specificity of swab cultures for SSIs were evaluated. RESULTS: The study included 422 patients categorized into two groups, swab and nonswab, depending on whether swab cultures were implemented during cranioplasties. The overall infection rate was 7.58%. No difference was seen in infection rates between groups. There were 18 false-positive and no true-positive swab culture results. All bacteria between swab cultures and SSI cultures were discordant. Meanwhile, there were 19 false-negative swab cultures. The results showed high specificity but low sensitivity for swab cultures to predict SSI occurrence and the pathogens. CONCLUSIONS: Owing to low accuracy and sensitivity, swab cultures of cryopreserved autografts should not be routinely performed during delayed cranioplasties.

Case history on Epstein-Barr Virus-associated smooth muscle tumor (EBV-SMT) of cranio-cervical junction in an immunocompetent patient.

Epstein-Barr virus-associated smooth muscle tumor (EBV-SMT) is a rare mesenchymal tumor that almost exclusively occurs in immunocompromised hosts. Here, we report a 75-year-old Taiwanese woman without definite immune-deficient history presenting with progressive occipital neuralgia, low cranial nerve deficits (CN9-12) and cervical (C1-C5) radiculopathy. Magnetic resonance imaging revealed a 4.5*4.0*6.7 cm infiltrating mass occupying posterior skull base and C1-C2 vertebra and C1-5 epidural extension with bone destruction and vertebral artery (VA) encasement. There was also a synchronous 2.7 cm tonsillar tumor. A two-stage operation for cranio-cervical tumor excision and stabilization was performed. Tumor was confirmed directly arising from VA intraoperatively. Pathology reported a spindle cell neoplasm and the diagnosis of EBV-SMT was confirmed by EBER (EBV-encoded small RNA) in situ hybridization. An immune survey and reconstruction should be conducted for patient with EBV-SMT. A near-total resection of tumor may be beneficial for local control, however, the role of surgical resection in treating CNS EBV-SMT remains to be determined.

Modified Balloon-in-Stent Technique for Circumferential Vertebral Artery Dissecting Aneurysm.

BACKGROUND: Treatment for circumferential vertebral artery dissecting aneurysms (VADAs) remains challenging. Stent-assisted coil embolization is the most common treatment technique. However, this approach presents high rates of incomplete occlusion and recurrence, often requiring the addition of second or third stents for reconstruction. A flow diverter may achieve favorable clinical outcomes, but it cannot result in immediate aneurysm occlusion and is limited by strict antiplatelets and expensive price. We report excellent results of a 1-stage modified balloon-in-stent technique for circumferential VADA. METHODS: A total of 12 patients were treated with the modified balloon-in-stent technique for VADAs. A homogeneous coil was used to fill the aneurysm sac, followed by deployment of 1 self-expandable stent and in-stent Scepter balloon angioplasty. Clinical presentations, outcomes, and imaging results were evaluated over at least 2 years of follow-up. RESULTS: Our 12 patients were examined during a mean follow-up period of 36.2 months (range, 2-5 years). The initial symptoms presented included subarachnoid hemorrhage (5 of 12; 41.7%), ischemia (3 of 12; 25.0%), and nonischemia (4 of 12; 33.3%). The modified BIS technique and coil embolization were successful in all patients. No technique-related complications or recanalization occurred during follow-up. CONCLUSIONS: We demonstrated an innovative modified BIS technique to treat circumferential VADA by using a coiling basket followed by the deployment of a self-expandable stent and in-stent Scepter balloon angioplasty. This strategy is safe, feasible, and cost effective and was not associated with recurrence or complications over at least 2 years of follow-up.

Traumatic aneurysm at the superior cerebellar artery: illustrative case.

BACKGROUND: Traumatic aneurysms at the superior cerebellar arteries after head injury are extremely rare and may be overlooked. Rupture of these aneurysms can cause fatal intracranial hemorrhages; thus, early identification of the entity helps prevent detrimental outcomes. OBSERVATIONS: A patient suffered from sudden severe headache and decreased consciousness level several weeks after a blunt head injury. He received surgery to remove a progressive enlarging subdural hematoma. The diagnosis of a traumatic aneurysm at the superior cerebellar artery was delayed, made only after a recurrent subdural hemorrhage occurred. He received another surgery to obliterate the aneurysm. LESSONS: The patient could have been treated earlier if traumatic aneurysm had been suspected in the beginning. In addition to the case, the authors also reviewed the literature to clarify the pathophysiology, clinical presentation, diagnosis, and management of the disease.

Theta Oscillations at Subthalamic Region Predicts Hypomania State After Deep Brain Stimulation in Parkinson's Disease.

Subthalamic nucleus (STN) deep brain stimulation (DBS) is an effective treatment for the motor impairments of patients with advanced Parkinson's disease. However, mood or behavioral changes, such as mania, hypomania, and impulsive disorders, can occur postoperatively. It has been suggested that these symptoms are associated with the stimulation of the limbic subregion of the STN. Electrophysiological studies demonstrate that the low-frequency activities in ventral STN are modulated during emotional processing. In this study, we report 22 patients with Parkinson's disease who underwent STN DBS for treatment of motor impairment and presented stimulation-induced mood elevation during initial postoperative programming. The contact at which a euphoric state was elicited by stimulation was termed as the hypomania-inducing contact (HIC) and was further correlated with intraoperative local field potential recorded during the descending of DBS electrodes. The power of four frequency bands, namely, θ (4-7 Hz), α (7-10 Hz), ß (13-35 Hz), and γ (40-60 Hz), were determined by a non-linear variation of the spectrogram using the concentration of frequency of time (conceFT). The depth of maximum θ power is located approximately 2 mm below HIC on average and has significant correlation with the location of contacts (r = 0.676, p < 0.001), even after partializing the effect of α and ß, respectively (r = 0.474, p = 0.022; r = 0.461, p = 0.027). The occurrence of HIC was not associated with patient-specific characteristics such as age, gender, disease duration, motor or non-motor symptoms before the operation, or improvement after stimulation. Taken together, these data suggest that the location of maximum θ power is associated with the stimulation-induced hypomania and the prediction of θ power is frequency specific. Our results provide further information to refine targeting intraoperatively and select stimulation contacts in programming.

Direct Carotid Artery Exposure for Acute Cerebral Infarction in Hybrid Angiography Suite: Indications and Limitations.

OBJECTIVES: For the endovascular intervention of acute ischemic stroke, a transcervical route is an alternative approach in patients with challenging anatomical variations. Percutaneous puncture is a common way, but it can cause many fatal complications. Direct carotid artery exposure is an alternative for reducing complications. We demonstrate a technique of direct carotid exposure in patients for whom transfemoral or transbrachial approaches were impossible. We present patient outcomes and discuss the indications and limitations of this procedure. METHODS: We retrospectively reviewed the cases of patients undergoing direct carotid exposure for acute ischemic stroke in a hybrid angiography suite and presented the details of the technique. RESULTS: Among 548 consecutive patients with acute large vessel strokes who were treated by emergency endovascular thrombectomy or stenting between January 2015 and September 2020 in our center, only 8 (1.46%) required a transcervical approach. Of them, 7 underwent direct carotid exposure with successful recanalization and good clinical outcomes. CONCLUSIONS: Direct carotid exposure for endovascular stroke treatment is effective and advantageous in patients with challenging anatomical variations. Performing this procedure in carefully selected patients in the hybrid angiography suite can be beneficial in terms of open surgeries, saving time, and decreasing the risk of postoperative complications.

Early strategy of scepter XC balloon angioplasty and simultaneous Nimodipine infusion for vasospasm following ruptured aneurysm.

BACKGROUND: Cerebral vasospasm still results in high morbidity and mortality rates in patients after aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to establish a protocol for the management of vasospasm and demonstrate our experience of angioplasty using the Scepter XC balloon catheter. METHODS: In this retrospective study, a computed tomography angiography and perfusion image was arranged if early symptoms occurred or on the 7th day following aneurysmal SAH. In patients with clear consciousness, balloon angioplasties were performed for symptomatic vasospasms, which were not improved within 6-12 h after maximal medical treatments. In unconscious patients, balloon angioplasties were performed for all patients with angiographic vasospasms. RESULTS: Fifty patients underwent Scepter XC balloon angioplasty among 396 consecutive patients who accepted endovascular or surgical treatments for ruptured aneurysms. All angioplasty procedures were successful without complications. 100% angiographic improvement and 94% clinical improvement were reached immediately after the angioplasties. A favorable functional outcome (modified Rankin Score of ≤2) could be achieved in 82% of patients. Even in patients with poor clinical grading (Hunt-Hess grade 4-5), a clinical improvement rate of 87.5% and favorable outcome rate was 70.8% could be achieved. CONCLUSION: Balloon angioplasty with Scepter XC balloon catheter is safe and effective for post-SAH vasospasm. This device's extra-compliant characteristics could considerably improve the quality of angioplasty procedures. For all patients, even those with poor neurological status, early treatment with combined protocol of nimodipine and angioplasty can have good clinical outcomes.

Endovascular Treatment of Ruptured Proximal Segment of the Anterior Cerebral Artery Aneurysms: Single-Center Experience and Literature Review.

BACKGROUND: Proximal anterior cerebral artery (A1) aneurysms are rare among all intracranial aneurysms and are regarded as difficult to treat endovascularly. Treatment is even more challenging in patients with ruptured aneurysms and acute subarachnoid hemorrhage owing to the small size and proximity to perforators. Though challenging, endovascular treatment can provide favorable outcomes in such patients. We report our case series of endovascular treatment in ruptured proximal A1 aneurysms. METHODS: Between January 2010 and December 2017, 1200 aneurysms were treated endovascularly at our center. There were 15 patients with 15 ruptured proximal A1 aneurysms who presented with subarachnoid hemorrhage. Five patients underwent simple coiling, 9 underwent balloon-assisted coiling, and 1 underwent catheter protective coiling. Medical records and angiographic results were obtained retrospectively. RESULTS: All aneurysms were successfully treated with endovascular techniques. Multiplicity rate was 53.3% (n = 8). Initial complete obliteration rate was 93.3% (n = 14), with a 13.3% recurrence rate (n = 2). One patient experienced intraoperative bleeding; this was the only procedure-related complication. Eleven patients (73.3%) had a good clinical outcome. When excluding Hunt and Hess grade 4 patients, the good outcome rate was 81.8%. CONCLUSIONS: Ruptured proximal A1 aneurysm is a rare condition and is highly associated with multiple aneurysms. Despite being a more difficult and complicated technique, endovascular coiling performed in high-volume, experienced medical centers is an effective modality with excellent clinical outcomes.